Laparoscopic Appendectomy
Write the first paragraph of your page here. Dr. Shew Key Materials 15 blade scalpel Laparoscopy kit with 5 mm 30 deg scope GIA blue load for appy, white load for mesoappendix Bovie with pointed tip S retractor 2-0 vicryl with UR needle 5-0/4-0 monocryl for skin 0.25% marcaine Operative Steps 1. Grasp umb with adsons, vertical midline incision with 15 blade through skin 2. Using cut, bovie through dermis - always towards yourself, anchor your hand with pinky 3. Bovie through subQ to umb ring with coag 4. Dilate umb ring with kelly forceps 5. Insert 12 mm trocar, parallel to abd wall, pinching and pulling up on abd wall 6. Attach gas, start insufflation to 15 mm Hg 7. Using 5 mm 30 deg scope view bowel below, inspect RLQ, liver, pelvis. If bladder distended -> suprapubic pressure to decompress if foley in. 8. Make 5 mm suprapubic incision through dermis (no cautery), insert 5 mm trocar 9. Make 5 mm LLQ incision through dermis (no cautery), insert 5 mm trocar. Place camera in LLQ trocar. 10. Platypus in left hand, marilyn in right, go above Dr. Shew. 11. Grasp omentum, lift towards head off cecum/appy 12. Bluntly removed adhesions if present 13. Grasp appy 2-3 cm from base, lift up and toward pelvis. 14. Using marilyn create avascular window near base of appy with pushing in/spreading (no need to remove all the way). Keep eye on tips. Once through, dilate with big spreads. 15. Keep holding with left, using GIA blue load in right hand, make sure smaller jaw is facing camera before inserting. 16. Put small jaw through window, GIA around appy, make sure you don't bite excess cecum, close, load, fire. 17. Insert white load for mesoappendix. Get around meso appendix, low as you can, close, load, fire. 18. Insert endocatch, place in bag, pull gold ring -> cut suture -> pull handle, remove endocatch and leave bag (unless bag just comes with you) 19. Using platypus and instrument of choice, inspect staple line. No suction/irrigation needed if no blood/pus. 20. Pull omentum back over cecum/staple line 21. Remove 5 mm trocars under direct vision 22. If fascia visible through skin, close with 2-0 vicryl on UR needle 23. Inject 0.25% marcaine to peritoneum at trocar sites 24. Deflate umb trocar balloon, remove 25. Need: S tractor, kocher, bonnie pickups. Close with 2-0 vicryl with UR needle using figure of eights. 26. Close umb with 5-0 monocryl with running sutures. Finish with aberdeen-hitch (sp?), Shew style: Do standard sub-cuticular, but the last three bites are: A. last bite leading to your final loop. B. Sub-cuticular bite from final loop to same side near apex C. Enter SUPERFICIAL opposite side at apex, exit DEEP near bite A. (See photo). http://uclasurgery.wikispot.org/Lap_Appy?action=Files&do=view&target=photo.jpg 27. Close 5 mm ports with interrupted buried 5-0 or 4-0 monocryl 28. Mastasol -> steri 28. Wad up a 2x2 for umb as "pressure dressing" with tegaderm. Opsite/2x2 with tegaderm for 5 mm ports. Dr. Brunicardi Key Materials 11 blade scalpel Laparoscopy kit with 10 mm and 5 mm 30 deg scopes GIA with blue load for appy, grey load for mesoappendix 0-0 vicryl sutures on CT needle x2-4 S retractors Operative Steps 1. Grasp umbilicus with adsons, vertical midline incision with 11 blade 2. Using kelly forceps, dilate umbilical ring 3. Place 12 mm trocar through umbilicus, angle parallel to abdominal wall 4. Attach CO2, insufflate to 15 mm Hg 5. Using 10 mm 30 deg scope, examine bowel underneath trocar, cecum/appy, liver, pelvis 6. Place suprapubic 5 mm trocar using trocar sheath w/ metal tip (palm instrument with right, direct with left). Once tenting peritoneum, direct towards appy 7. Place 5 mm trocar through trocar sheath 8. Place LLQ 5 mm trocar lateral to ASIS, at level or slightly below level of umb 9. Using two kittners, lift omentum cranially if covering cecum/appy 10. Bluntly dissect adhesions, if present. 11. Once appendix visualized, use silver handle grasper in left hand to grab appy ~2-3cm from base 12. Using kittner in right hand, use "drilling" motion to create avascular window near base of appy - keeping tension with left hand 13. Dilate window using kittner 14. Switch to 5mm 30 deg scope, get GIA blue load 15. Place camera in LLQ port, GIA in umb port 16. Put smaller "jaw" of GIA through window, visualize tips on other side of appy. Push in, close jaws, fire GIA. Dis-articulate and remove GIA. 17. Using grey load, divide mesoappendix 18. If remnant left, can use repeat grey load vs scissors with cautery. If bleeding vessel, use endoloop (keep endoloop at 6 o'clock position while cinching). 19. Insert endocatch, turn bag toward camera, place appy in, pull gold ring -> cut string -> pull white handle -> pull endoloop, leaving specimen bag 20. No need to clamp string on specimen bag 21. Switch back to 10 mm 30 deg scope 22. Using kittner/silver handle and suction/irrigator inspect staple lines. Suction blood if necessary. If pus, irrigate/suction. 23. Eval for subhepatic/pelvic fluid 24. Can pull omentum over cecum/staple line 25. Remove trocars under direct vision 26. For umbilical closure: 2 S retractor, 2 vascular clamp, 0-0 vicryl suture on (?CT) needle x2-4, 3 clamps 27. Dr. Brunicardi will retract opposite edge with S retractor, place vascular clamp handle below fascia 28. Grab fascia with pick-up, aim needle far back, make contact with handle and follow it out. On opposite bite, curve in along with pick-up handle and come out next to S retractor. 29. Clamp each suture 30. Using finger, sweep below to ensure no bowel/omentum caught in sutures 31. Pull up on sutures, tie each one w/ 8 knots, cut 32. Re-approximate umbilicus with 4-0 monocryl interrupted buried sutures, invert 33. Close 5 mm sites with buried interrupted 4-0 monocryl 34. Mastasol -> steris -> Op-sites Dr. Chen "Key Materials" "Operative Steps" 1. Make 5 mm transverse incision to left of umbilicus just through skin/dermis - use cautery PRN to go through dermis, spread with hemostat 2. Using optiview trocar and zero degree scope make large spins with trocar ONLY clockwise. Watch for visual cues to go fat->scarpa->ant sheath->muscle->posterior sheath 3. When the peritoneum is reached, change the angle to tent the peritoneum and spin through. Watch for peritoneum (white) superiorly and omentum/bowel inferiorly (yellow/pink). 4. Change to 30 degree scope, survey abd 5. Attach gas, insufflate to 15 mmHg 6. Place LLQ trocar site (5 mm) as lateral as possible, triangulating towards appendix. IF FEMALE PT, keep as low as possible (for cosmesis). Can use prior pfannanstiel if present. 7. Place suprapubic trocar (12 mm) 8. Using platypus in right and left hands, lift omentum cranially 9. If needed, sweep ileum/small bowel away 10. If appendix not visualized, grasp cecum with large, broad grasps 11. If hindered by lateral attachments, use hook with electrocautery to lift thin attachments up and away from appy/cecum and buzz through 12. Using maryland, turn tips towards appy and create avascular window. Technique is to push in, spread, come out, close your tips, repeat. Once through, insert platypus and spread again to widen window. 13. Take blue load GIA endo stapler in left hand, insert smaller jaw into your window. Staple and divide base of appendix. 14. Regrasp appendix at the mid-point of attachment of mesoappendix to give yourself the best view. Divide mesoappendix with white load GIA stapling device. 15. Place specimen in endocatch. 16. Remove specimen through the trocar. If unable to, remove the trocar & specimen together and then replace trocar. 17. Use platypus and suction-irrigator, suction fluid/blood from RLQ/infrahepatic fossa/pelvis and inspect staple line. Technique: grasp suction-irrigator with the instrument tip extending out between the index and middle finger, operating buttons with thumb. 18. Remove suprapubic and LLQ trocars under direct vision 19. Release pneumoperitoneum. Remove umb trocar OVER the camera, leave the scope in place. Then slowly withdraw the scope to examine the peritoneum, fascial layers 20. Using S-retractors for the 12 mm port, grasp edges of peritoneum with kochers 21. Using 0-0 vicryl on UR needle place a figure of eight stitch to close peritoneum 22. Close all ports with single buried interrupted 4-0 monocryl. Dress with mastasol/steri/tegaderm. Dr. Hsu Key Materials Operative Steps 1. Choose either incision through umbilicus vs infraumbilical fold 2. Grasp umb with adsons, cut vertically with 11 blade 3. Place tonsil, closed, through umb ring. Don't spread. 4. Made incision with cautery through umb ring to accomodate finger 5. Use kocher to grab fascia, place two interrupted 2-0 vicryl through fascia, snap. 6. Insert 11 mm trocar, insufflate, view with 5 mm thirty degree scope 7. Place 5 mm suprapubic trocar under direct vision 8. Place LLQ 5 mm trocar under direct vision 9. Place camera in LLQ trocar 10. Using suprapubic and umb trocars, first two platypus in each hand 11. Position patient left side down, head down 12. Lift omentum cranially 13. Using open platypus, push small bowel medially and superiorly out of way. Few grasps of bowel as possible, and always use LARGE grasps 14. If needed, rotate cecum medially/laterally 15. Bluntly dissect adhesions from appendix without grasping appy if possible 16. Grasp appy near base, exchange for maryland in right hand, and insert into avascular window - go through and through (gently) WITHOUT spreading if possible 17. If unsuccessful, can attempt with kittner as well 18. Once through, exchange right hand for platypus again, attempt to place through same window. AGAIN, WITHOUT spreading. "If it can fit a platypus, it can fit a stapler" 19. First ask for GIA white (vascular) load "Easier to define where to divide appendix if you divide mesoappendix first" 20. Grasp appendix at midpoint of mesoappy you will divide. Divide mesoappy with white GIA stapler 21. Once freed, divide appendix near base of cecum with blue load GIA stapler 22. Place in endocatch 23. Remove specimen (with trocar if needed) 24. Replace trocar, camera. Obtain platypus and suction/irrigator. Irrigate and suction near staple line to eval for hemostasis. 25. Irrigate/suction over liver, down in pelvis. 26. Inject marcaine under direct vision into trocar sites, remove trocars under direct vision 27. Tie vicryl sutures in umbilical incision. Place buried interrupted 4-0 monocryl sutures to close umb. 28. Close 5 mm trocar sites with single buried 4-0 monocryl Dr. (Maggard)-Gibbons Key Materials 5 mm optiview trocar (called clear trocar) "Hiyama" tray 5 mm zero and thirty degree scope 30 mm (short) endo GIA endostitch sharp 12 mm trocar and 2x 5mm trocar Incision is placed superior and left of umbilicus, midpoint of rectus Make 5 mm incision with an 11 blade: hold it vertical, "scratch the skin open." Use "cut" on cautery to open dermis. Insert 5 mm optiview trocar with 5 mm zero degree scope, use 180-270 turns back and forth. Go through fat>scarpa>anterior fascia>rectus>posterior. Once you reach posterior, push through, change angle, push in. Attach gas, insufflate to 15 mm Hg Switch to 30 degree 5 mm scope, survery abdomen Insert 12 mm trocar at LLQ (scratch open, dilate with tonsil, use sharp 12 mm trocar), 5 mm trocar above pubis. Switch to platypus in both hands Lift omentum cranially, push small bowel to pelvis to view cecum/appy Once appendix identified, grasp, follow to tip Then follow to base of appendix, use maryland to bluntly dissect avascular window Then switch back to platypus, "use as if it's a stapler" Staple base of appendix with endoGIA 30 mm blue load Staple mesoappendix with endoGIA 30 mm white load Place in endocatch, remove specimen with 12 mm trocar Replace 12 mm trocar Examine staple lines, suction fluid with pelvis, RLQ Remove trocars under direct vision Close fascia of 12 mm trocar with 0-0 vicryl on endostitch device Evacuate insufflation, close skin with 4-0 monocryl Dr. Tillou #Using two adsons pick up on umbilicus and cut down through dermis with 15 blade. #Use cautery down through linea alba #Clamp peritoneum and divide with mets #Sweep with finger #Place two interrupted PDS in fascia, clamp #Clamp fascia with kocher to lift up, insert 12 mm trocar #Place 10 mm 30 degree scope, examine abdomen #Place 5 mm suprapubic port #Place 5 mm LLQ port triangulating to appendix #Use two atraumatic bowel graspers to find appendix **adherent to peritoneum* #Bluntly sweep small bowel from appendix #Using Maryland with cautery, dissect adhesions by inserting under thin lip then spread. Pick up small lip and cauterize while lifting up and away. #Given difficulty, divide base first #Make avascular window near base of appendix with Maryland. #Switch to platypus and spread in window #Staple with endo GIA blue load #Dissect adherent appendix from cecum, define mesoappendix so you can staple across without appendix #Staple mesoappendix with white load endo GIA #Place in endocatch, remove appy with 12 mm trocar, replace trocar #Observe staple lines #Irrigate clots and suction #Inject marcaine into ports, then remove under vision #Place additional figure of eight into fascia as needed, tie fascial suture #Irrigate umb wound #Close umb with interrupted monocryl. Place 2x2 in umb. #Close trocar with interrupted monocryl and place steristrip and mastisol.